Tests point to plagueOne more death takes toll to fourChitleen K. Sethi
Tribune News Service

Chandigarh, February 18
Even as the PGI has decided to wait for a final confirmation from the National Institute of Communicable Diseases, (NICD), New Delhi of the exact cause of the disease which has today claimed its fourth victim, according to sources, the PGI’s own report on the results of its various microbiological tests conducted to identify the bacteria points to it being plague.

This will be the first outbreak of the disease in the country this century. The last incidence of plague was in 1994 at Surat which had claimed more than 200 lives all over the country, including some deaths in Punjab. The 1903 plague had claimed more than a million lives while the deadly plague which swept the world in the 14th century had wiped off half of India’s population.

Despite the fact that the plague is fast becoming a rural and semi-rural disease, because the number of cases of plague have been increasing annually, in the past 50 years it is categorised as a re-emerging infectious disease by the World Health Organisation. WHO has also listed Asia as one of the focal points of plague present in its rodent population with the main causes of its spread listed as hunting, skinning and consumption of infested animals.

The plague which has struck
Himachal Pradesh this time was being thought to be one of the many wild incidents of deaths due to unknown reasons which happen in the forest villages of the state till a whole family who had cared for a member, Randhir, started suffering from similar symptoms which he had died of. Randhir and his family had reportedly been visiting the forest for hunting before Randhir fell ill.

Anu, the 31-year-old who died at the PGI today, is the sister of Randhir, the first person to die of the disease. She was admitted to the PGI on February 13 and died early this morning. She had been on assisted breathing since admission and was said to be among the two of the seven patients who were in a serious condition. The condition of four of the remaining patients is said to be stable while two are still not out of danger.

“We had this death here today as the original damage to the lungs because of the infection was so much that it could not be recovered. But certainly these patients are not going to cause any fresh infection,’’ said doctors in the Department of Internal Medicine, PGI. Anu’s body’s was cremated after a post mortem here in the afternoon.

Sources in the PGI said the two children of the same family, who are admitted to the APC, are much better today and have shown no signs of developing any pneumonic illness.

The PGI has stated in a Press note that the culture from three patients show that there is a bacterial growth but to pin point the exact nature of the organism, the confirmation of the bacteria at the molecular level is essential, the facility of which is not available at the PGI. The same will be done at the NICD, keeping in mind the criteria laid down by WHO for the same. The report of the test called PCR (Polymerase chain reaction) is likely to be submitted by the NICD tomorrow morning.

Septicemic plague may result in sudden and intense shock
without signs of localized infection. A person may show
combinations of symptoms of any of these three types.

Untreated pneumonic and septicemic plague are invariably
fatal.

Early treatment with streptomycin or tetracycline improves
survival considerably.

WHO
Action Plan

Step
1 : Quarantine or cordon sanitarie or complete isolation

Step
2: Provide antibiotics

Step 3: Elimination of fleas

Step
4: Elimination of rats

Step 5: Political and
financial issues.

Plague
is a disease which exists in a “nest,” a reservoir of
animals which perpetuate the bacillus. For this disease to
emerge from the “silent zone” into infecting a human
population, four elements must converge in time and place to
cause the disease.

An agent (the bacterium Yersinia pestis),

A vector (the flea Xenopsylla cheopsis),

A reservoir (rat or ground squirrel) and

A human host, in this case Randhir, who was the first
to die of the disease and consequently spread it to his
family members as pneumonic plague.

Humans are an “accidental host”-they play no role in the
continuation of spread of plague in nature except in pneumonic
spread, person-to-person.

Shimla, February 18
The death of four persons due to the outbreak of “plague” in the Rohru area of the district has exposed the laxity of the health authorities who had ignored the warnings of an expert regarding recurrence of the disease.

This is for the third time that the disease has broken out in the area since 1965. The last time it was in 1982 when eight persons had died at Tangnu village.

It is being pointed out that although the authorities deserve appreciation for having swung into action well in time by taking steps to prevent the disease from becoming an epidemic, but implementation of the action plan recommended by Dr Jaidev Retola to combat its cyclic recurrence could have prevented the loss this time.

The problem appears to be under control now as no new patient has reported in any of the hospital during the past 92 hours. Dr Retola, who was among those doctors who fought the disease in 1982, got training by the National Institute of Communicable Disease (NICD) for the purpose.

In his action plan submitted to the authorities way back in 1990, Dr Retola had reportedly pleaded for surveillance in this plague-prone area. He had again written a letter to the Chief Medical Officer in 1996 expressing apprehensions that might break out again in the area. Dr Retola, who is heading the medical unit in the state Assembly, is again in the forefront fighting the disease in the Rohru subdivision.

Dr Ram Lal, Senior Medical Officer at Rohru, acted swiftly and administered antibiotics to the first patients which helped in saving many lives. He also reportedly informed the
PGI, Chandigarh, in this regard.

Shortage of doctors and paramedical staff in the area has been a longstanding problem which the authorities have so far not been able to meet.

Mr Virbhadra Singh, CLP leader and former chief minister, said today that the health institutions, including the Civil Hospital at Rohru and Jubbal, in spite of having the necessary infrastructure, were woefully short of doctors, paramedical staff and medicines. Had these been properly equipped, it would have been possible to treat all the patients in the hospital at Rohru itself thereby preventing the anxiety which has gripped other parts of the state also.

New Delhi, February 18
A day after Prime Minister Atal Behari Vajpayee sought details regarding reported cases of plague-like disease in Himachal from Chief Minister Prem Kumar Dhumal, the state government has submitted a report to the Prime Minister’s Office on the disease spread in Rohru subdivision in Shimla district. While confirming submission of the report to the PMO, Himachal Pradesh Chief Secretary Harsh Gupta said Professor Dhumal was personally monitoring and reviewing the situation.

He claimed that no new cases had been reported in the past five days and five patients admitted to the Community Health Centre in Rohru and nine patients admitted to the PGI, Chandigarh, were showing signs of quick recovery.

Meanwhile, a three-member team of the National Institute of Communicable Diseases (NICD) returned to the Capital today after collecting a variety of clinical samples of persons suspected to be infected with the plague-like disease. The team comprised an epidemiologist, Dr Avdesh, a biochemist, Dr Arvind Rai, and microbiologist, Dr Dipesh Bhattacharya.

Sources in the NICD said the team had submitted its preliminary findings to the NICD Director, Dr Usha Bawehja, who in turn had forwarded them to the Health Ministry.

It is noteworthy that the Union Health Minister, Dr C.P. Thakur, chose to keep his commitments of addressing election meetings in Varanasi on Monday. He is expected to return to the Capital on Tuesday.

Spelling out the preventive steps taken by the Himachal government, the State Chief Secretary said about 18,000 persons were provided medicines. He said 6,25,000 assorted capsules of doxycycline, tetracycline and septran had been despatched to the area. He said medical teams had been sent to affected areas where people had come into contact with patients. Apart from fumigation of houses, blood and sputum samples had been taken and persons had been out on prophylactic
treatment.

He said all educational institutions had been closed in the area and a mass awareness campaign had been launched to educate the people about the disease and the precautions to be taken.

While refusing to confirm that the preliminary opinion pointed to plague, the NICD sources said, “We have established some opinion. The Health Ministry will draw conclusions on the basis of consultation with experts and inputs from other institutes, including the PGIMER. By now, they must have drawn their conclusions.”

The sources said that round-the-clock tests are underway in the Zoonosis division of the NICD and the Biotechnology Department. While the Zoonosis division carried out tests like culture, anti-body test and phagelisys, the Department of Biotechnology is doing molecular characterisation. “We are looking for a gene which should be specific to that particular organism we are looking for. It could be plague or any other disease. These methods initially give a bacterial culture. The analysis finally tells us what bacteria it is. The second test is DNA fingerprint of disease organisms or pathogens. We are following the WHO guidelines for investigation in case of outbreak of a mysterious disease.”

The Union Health Ministry, which has been allaying fears about the possible outbreak of the dreaded disease, said the much-awaited report of the NICD would now be submitted on Tuesday evening.

Sources in the ministry said bacteriophage typing is mandatory as per WHO guidelines. Plague is a notifiable disease like cholera, dengue and yellow fever.

The sources in the NICD said that hundreds of bacteria could have plague-like properties and bacteriophage typing is a technique of identifying a particular kind of bacteria.

The sources said the biochemist was entrusted the task of collecting correct clinical material from the PGI, Chandigarh where nine persons, including two children, suffering from the plague-like disease were under medication. The sources said while some clinical material had been passed on to the Zoonosios division, a part was retained by the Biotechnology Department.

Speaking on condition of anonymity, a microbiologist at the NICD said the epidemiologist played a very crucial role in tracing the infection but the final judgement is pronounced by the microbiologist. He said unless the final report came, no definite opinion could be given. He said laboratory consultation was indispensable in diagnosing plague.

Although sources said the samples were being tested in the Zoonosis division which dealt with diseases caused by animals, the head of the Zoonosis division, Dr R.L. Ishpujani, refused to comment.